Minnesota Health Care Programs *DHS-5591-ENG* MA and...
Transcript of Minnesota Health Care Programs *DHS-5591-ENG* MA and...
![Page 1: Minnesota Health Care Programs *DHS-5591-ENG* MA and …pathlore.dhs.mn.gov/.../Forms/M12_01_DHS_5591_Neleh.pdf · 2012. 6. 7. · DHS-5591-ENG Author: Minnesota Department of Human](https://reader036.fdocuments.in/reader036/viewer/2022081400/60ae43050676fa140b3332f1/html5/thumbnails/1.jpg)
CASE NAME CASE NUMBER l Application
l Renewal
DATE
HouseholdName Covered MPET Begin date HH size SSN U.S. Citizenship* Identity* Immigration
l MA
l MinnesotaCarel N/A
l Provided
l Exempt
l N/A l Verified
l Exempt – reason:l N/A
l Verified
l Exempt
l N/A l Verified
l Undocumented
Sponsor l Yes l No
l MA
l MinnesotaCarel N/A
l Provided
l Exempt
l N/A l Verified
l Exempt – reason:l N/A
l Verified
l Exempt
l N/A l Verified
l Undocumented
Sponsor l Yes l No
l MA
l MinnesotaCarel N/A
l Provided
l Exempt
l N/A l Verified
l Exempt – reason:l N/A
l Verified
l Exempt
l N/A l Verified
l Undocumented
Sponsor l Yes l No
l MA
l MinnesotaCarel N/A
l Provided
l Exempt
l N/A l Verified
l Exempt – reason:l N/A
l Verified
l Exempt
l N/A l Verified
l Undocumented
Sponsor l Yes l No
l MA
l MinnesotaCarel N/A
l Provided
l Exempt
l N/A l Verified
l Exempt – reason:l N/A
l Verified
l Exempt
l N/A l Verified
l Undocumented
Sponsor l Yes l No
IncomeName Earned income Unearned income Type(s) Frequency
l N/A l Verified l N/A l Verified
l N/A l Verified l N/A l Verified
l N/A l Verified l N/A l Verified
l N/A l Verified l N/A l Verified
l N/A l Verified l N/A l Verified
* Individuals receiving or who previously received SSI, SSDI, Medicare (or entitled to Medicare), non-IV-E or IV-E foster care or IV-E adoption assistance are exempt from requirement to document U.S. citizenship and identity.
Minnesota Health Care Programs
MA and MinnesotaCare Worker Verification Checklist
*DHS-5591-ENG*DHS-5591-ENG 3-11
![Page 2: Minnesota Health Care Programs *DHS-5591-ENG* MA and …pathlore.dhs.mn.gov/.../Forms/M12_01_DHS_5591_Neleh.pdf · 2012. 6. 7. · DHS-5591-ENG Author: Minnesota Department of Human](https://reader036.fdocuments.in/reader036/viewer/2022081400/60ae43050676fa140b3332f1/html5/thumbnails/2.jpg)
CASE NAME CASE NUMBER l Application
l Renewal
DATE
AssetsName Status Type
l Verified l None l N/A
l Verified l None l N/A
l Verified l None l N/A
l Verified l None l N/A
l Verified l None l N/A
Medical informationName Pregnant Disability or Blindness Emergency Insurance*
l N/A l Yes
l Verified – due date:l SSA l MA referral
l SMRT referral l N/Al N/A
l Verifiedl Access to l ESI l Within last 4 months
l Employer dropped l Cost effective
l N/A l Yes
l Verified – due date:l SSA l MA referral
l SMRT referral l N/Al N/A
l Verifiedl Access to l ESI l Within last 4 months
l Employer dropped l Cost effective
l N/A l Yes
l Verified – due date:l SSA l MA referral
l SMRT referral l N/Al N/A
l Verifiedl Access to l ESI l Within last 4 months
l Employer dropped l Cost effective
l N/A l Yes
l Verified – due date:l SSA l MA referral
l SMRT referral l N/Al N/A
l Verifiedl Access to l ESI l Within last 4 months
l Employer dropped l Cost effective
l N/A l Yes
l Verified – due date:l SSA l MA referral
l SMRT referral l N/Al N/A
l Verifiedl Access to l ESI l Within last 4 months
l Employer dropped l Cost effective
Notes
l MAXIS Case Notes entered
l MAXIS Case Notes N/A
l MMIS Case Notes entered
l MMIS Case Notes N/A
*Refer to HCPM 15.05, 15.10 and 15.10.05 for more information about insurance.